GW1--06164_Well Construction - GW1_20230922

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: '
14.WATERZONES
Josh Plemmons FROM ,TO DESCRIPTION
R. FL
Well Contractor Name
4137-A fL ft.
15.OUTER CASING(for-multicasedwells)ORL Ofap &able)
NC Well Contractor Certification Number _ FROM TO DIAMETy.ft I TRIO MATERIAL
Clearwater Well Drilling Inc. ift. (b` IL LO`Rli
In. 0Jo_
Company Name 16.INNER CASING OR TUBING(geothermal closes!-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft: d ! J V D53 0. R. in.
List all applicable well construction permits(Le County,State.Variance.eta) ft. R. In.
3.Well Use(check well use): 17.SCREEN - - I .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft. R. in.
°Agricultural OMtmicipal/Public '
°Geothennat(Heating/Cooling Supply) kesidential Water Supply(single)
ft• R. is
0Industrial/Commercial ❑Residential Water Supply(shared) 1&OMGROUT_
TO /MAATE�RIA�L 1- EMPLACEMENT METHOD&AMOUNT
l.l�.1 t❑Irrigation i ft- 2D R' t'l 1 1T r1I..Ct
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovety
Injection Well: ft. R.
[!Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery °Salinity Barrier R. ft. I
❑Aquifer Test OStonnwaterDrainage R. ft.
❑Experimental Technology °Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
Otleothemial(Closed Loop) °Tracer FROM TO DES IONror.audaess.selurocktsotarllnzhr.
ete.)
❑Geothermal(Heating/Cooling Return) °Other(explainunder#21 Remarks) 1 - k . , �/--
15i. 1F rant I
4.Date Wells)Completed: /� (Weell.�ID# • q, R, t f
5a.Well Location: F Cf i t(.CO r,u \CtC� tI it 1t 1000"� lOrn, fl Illl,,,,,,000ie, i ..y' -,•�
De 1�115 c't— eret. i 'R! ', ••4 16 �.r r tf t i
Facility/OwnerName a Facility ID#(if applicable) R. ft.
50 gYAW—e, V.idole, M0.00n ` 3C, ft. R. SEP 9 9 'nn
nl
re d LULJ
Physical Address,City,and Zip 21.REMARKS lrtfiy=mt- ion l P r e”
-.?:::g URA
M
�nOW 1 i J
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C - cation:
(ifwell field,one lat/llong is sufficient)ic Q`�] I ]� , Q `�
35`03r 1S ..J1 N U(1� on t�� , () 3 w
1 true of Certified Well Contractor ; Date
6.Is(are)the well(s): Permanent or °Temporary y signing this form.l hereby certify that the well(s) ins(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200!"ell Construction Standards and that a
7.Is this a repair to an existing well: °Yes or Xlo - copy of this record has been provided to the well ouster
If this Is a repai.fill out known well construction Information and esplain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of thisform
You may use the back of this page.to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additi al pages if necessary.
For multiple injection or non-wntersupply wells ONLY with the same construction.you can submit t. SUBMITTAL INSTUCTIONS
9.Totaall w wellell 40s depth below land surface: (ft:) 24a. For All Welts: Submit this form withi 30 days of completion of well
Formultiple wells list all depths ijdifferent(erample-3@200'and 2©100') construction to the following:
6
10.Static water level below top of casing: (0 O (ft.) Division of Water Quality,Inform tion Processing Unit,
!firmer level is above casing.use"+"( 1617 Mail Service Center,Ral ,NC 27699-1617
'
11.Borehole diameter. I (in.) 24b.For infection Wells: In addition to sen ing the form to the address in 24a
r � above,also submit a copy of this form wt n 30 days of completion of well
IL Well construction method: 1 YV�C construction to the following: 1
(i.e.auger,salary,cable,direct push,etc.) Division of Water Quality,Undergroun Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, gh,NC 27699-1636
3 Method of test: 24c.For Water Supply&infection Wells: addition to sending the form to
13a.Yield(gpm) the address(es) above,also submit one copy of this form within 30 days of
Amount: completion of well construction to the co health department of the county
13b.Disinfection type: where constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Qui ity Revised Jan.2013